Includes certain out of home services such as transition from a hospital, nursing facility or other institutional setting to the home within home care insurance coverage.
NEW YORK STATE ASSEMBLY MEMORANDUM IN SUPPORT OF LEGISLATION submitted in accordance with Assembly Rule III, Sec 1(f)
BILL NUMBER: A3903
SPONSOR: Simon TITLE OF BILL:
An act to amend the insurance law, in relation to including certain out
of home services such as transition from a hospital, nursing facility or
other institutional setting to the home within home care insurance
coverage
PURPOSE:
To update and align the Insurance Law specifications for home care
coverage with the current system of hospital and medical practice
SUMMARY OF PROVISIONS:
The current State Insurance Law provisions for home care specify cover-
age for these services when under the care of a physician, established
and approved in writing by the physician, and provided by state
certified/licensed home care agencies. The bill maintains these baseline
standards for coverage while updating the 40+ year-old specifications
for: a covered individual's receipt of services, the listed services
that certified/licensed agencies actually provide, and the cost and
utilization control mechanisms now used by insurers.
Specifically, sections one and two, respectively, amend § 3221 and §
4303 of the insurance law to update the following in each section:
*Consistent with current hospital and medical care practice, the bill
modernizes the specifications for the covered individual to be for an
individual who requires services for: (i)transition from a hospital,
nursing facility or other institutional setting to home;(ii) rehabili-
tation, recovery or medical management at home following hospitalization
or institutional care; or (iii) medical management of a condition
predisposing the covered individual to hospitalization or confinement in
a nursing facility or to the need for other out-of-home services other-
wise covered under the contract or policy if home care is not provided.
*Updates the reference to a home care agency's authorized list of
services (now specified in § 3221 and § 4303 as nursing, home health
aide, physical therapy, occupational therapy or speech therapy) to
reflect other services the agency actually provides which include social
work, respiratory therapy and nutritional counseling, which are likewise
proven vital to cost-effective and necessary care in the modern delivery
system.
*Replaces outdated mechanisms for utilization and cost controls (e.g.,
replaces the existing law's 40 visit minimum) with contemporary and more
dynamic controls used in insurance and managed care, such as management
or utilization review of home care benefits, or use of preauthorization
and appropriateness criteria as to the level and intensity of treatment
applicable to home care.
Section three provides the effective date.
JUSTIFICATION:
This bill provides long overdue updates to antiquated sections of the
State Insurance Law that stipulate the coverage for home care services.
The current home care coverage provisions, adopted in the early 1970s,
were written and set forth for the health care system as it existed at
that time.
In that era:
*Hospitals were reimbursed per diem and without today's limitations on
length of stay; many of today's complex procedures did not exist, nor
did cases of such brief, even same-day, turnarounds; patients being
discharged were nowhere near today's level of continuing, intense and
complex medical need.
*Nursing homes were the primary health system option for chronically
ill, unlike today where home care plays a dominant role. *Transition of
patients from hospitals to home, or from nursing homes (particularly
rehab patients) to home, was not the major, complex hurdle that it is
today, nor the level of priority-medical focus that today is addressed
substantially through home care-hospital-physician partnership.
*Today's technologies for delivery of services and comprehensive medical
management between physicians and home care agencies (such as
telehealth/telemedicine) did not exist.
*Home care itself was not the integrated and heavily relied-upon model
evidenced in today's system.
The type of system that framed the now 40+ year-old insurance law
provisions bears little resemblance to the health care system of today.
This bill's modernization of the law would delineate the conditions of
home care coverage consistent with today's state of the art health and
medical care practices. It would support the operation of the entire
health care system, synchronize coverage to the newest models and inno-
vations of care, promote cost-savings and efficiency, and most impor-
tantly benefit covered individuals. It would also preserve and enhance
the original statue's intent of utilizing home care to prevent avoidable
hospitalizations, emergency room use and other higher cost medical
services use.
LEGISLATIVE HISTORY:
2023-24: A7953 Simon -referred to insurance
2021-2022: A380 -referred to insurance
2019-2020: A.408 - Referred to Insurance
2017-2018: A.54 - Referred to Insurance
2015-2016: A.7706A - Referred to Insurance
FISCAL IMPLICATIONS:
This bill will promote increased cost-efficiency and savings in the
health care system.
EFFECTIVE DATE:
The bill would take effect on the first of January next succeeding the
date on which it shall have become a law and shall apply to all policies
and contracts issued, renewed, modified, altered or amended on or after
such date.
